Healthcare Provider Details

I. General information

NPI: 1134108327
Provider Name (Legal Business Name): VISTA HEALTHPLAN OF SOUTH FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S PARK RD
HOLLYWOOD FL
33021-8593
US

IV. Provider business mailing address

300 S PARK RD
HOLLYWOOD FL
33021-8593
US

V. Phone/Fax

Practice location:
  • Phone: 954-962-3008
  • Fax:
Mailing address:
  • Phone: 954-962-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number03-
License Number StateFL

VIII. Authorized Official

Name: MS. DARCEY A. GARTNER
Title or Position: VICE PRESIDENT OF COMPLIANCE
Credential: CHC
Phone: 954-965-3118